AMERICA'S PRIDE SUPPORTING SERVICE CONNECTED DISABLED VETERANS, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan AMERICA'S PRIDE, INC. HEALTH & WELFARE TRUST
401k plan membership statisitcs for AMERICA'S PRIDE, INC. HEALTH & WELFARE TRUST
| Measure | Date | Value |
|---|
| 2018 : AMERICA'S PRIDE, INC. HEALTH & WELFARE TRUST 2018 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2018-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-12-31 | $6,073 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-12-31 | $47,424 |
| Total income from all sources (including contributions) | 2018-12-31 | $272,299 |
| Total loss/gain on sale of assets | 2018-12-31 | $0 |
| Total of all expenses incurred | 2018-12-31 | $292,497 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2018-12-31 | $235,145 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2018-12-31 | $271,204 |
| Value of total assets at end of year | 2018-12-31 | $180,335 |
| Value of total assets at beginning of year | 2018-12-31 | $241,884 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2018-12-31 | $57,352 |
| Total interest from all sources | 2018-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2018-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2018-12-31 | No |
| Administrative expenses professional fees incurred | 2018-12-31 | $26,350 |
| Was this plan covered by a fidelity bond | 2018-12-31 | Yes |
| Value of fidelity bond cover | 2018-12-31 | $75,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2018-12-31 | No |
| Contributions received from participants | 2018-12-31 | $93 |
| Assets. Other investments not covered elsewhere at end of year | 2018-12-31 | $0 |
| Assets. Other investments not covered elsewhere at beginning of year | 2018-12-31 | $0 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2018-12-31 | $152,372 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2018-12-31 | $0 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2018-12-31 | $10,586 |
| Other income not declared elsewhere | 2018-12-31 | $1,095 |
| Administrative expenses (other) incurred | 2018-12-31 | $19,914 |
| Liabilities. Value of operating payables at end of year | 2018-12-31 | $6,073 |
| Liabilities. Value of operating payables at beginning of year | 2018-12-31 | $41,484 |
| Total non interest bearing cash at end of year | 2018-12-31 | $149,202 |
| Total non interest bearing cash at beginning of year | 2018-12-31 | $190,595 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-12-31 | No |
| Value of net income/loss | 2018-12-31 | $-20,198 |
| Value of net assets at end of year (total assets less liabilities) | 2018-12-31 | $174,262 |
| Value of net assets at beginning of year (total assets less liabilities) | 2018-12-31 | $194,460 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2018-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2018-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2018-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2018-12-31 | $51,755 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2018-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2018-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2018-12-31 | No |
| Contributions received in cash from employer | 2018-12-31 | $271,111 |
| Employer contributions (assets) at end of year | 2018-12-31 | $31,133 |
| Employer contributions (assets) at beginning of year | 2018-12-31 | $40,703 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2018-12-31 | $31,018 |
| Contract administrator fees | 2018-12-31 | $11,088 |
| Liabilities. Value of benefit claims payable at end of year | 2018-12-31 | $0 |
| Liabilities. Value of benefit claims payable at beginning of year | 2018-12-31 | $5,940 |
| Did the plan have assets held for investment | 2018-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2018-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2018-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2018-12-31 | Unqualified |
| Accountancy firm name | 2018-12-31 | CLIFTONLARSONALLEN, LLP |
| Accountancy firm EIN | 2018-12-31 | 410746749 |
| 2017 : AMERICA'S PRIDE, INC. HEALTH & WELFARE TRUST 2017 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2017-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-12-31 | $47,424 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-12-31 | $56,742 |
| Total income from all sources (including contributions) | 2017-12-31 | $373,125 |
| Total loss/gain on sale of assets | 2017-12-31 | $0 |
| Total of all expenses incurred | 2017-12-31 | $425,813 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2017-12-31 | $313,887 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2017-12-31 | $373,125 |
| Value of total assets at end of year | 2017-12-31 | $241,884 |
| Value of total assets at beginning of year | 2017-12-31 | $303,890 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2017-12-31 | $111,926 |
| Total interest from all sources | 2017-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2017-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2017-12-31 | No |
| Administrative expenses professional fees incurred | 2017-12-31 | $18,250 |
| Was this plan covered by a fidelity bond | 2017-12-31 | Yes |
| Value of fidelity bond cover | 2017-12-31 | $75,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2017-12-31 | No |
| Assets. Other investments not covered elsewhere at end of year | 2017-12-31 | $0 |
| Assets. Other investments not covered elsewhere at beginning of year | 2017-12-31 | $0 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2017-12-31 | $15,813 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2017-12-31 | $10,586 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2017-12-31 | $91,515 |
| Administrative expenses (other) incurred | 2017-12-31 | $34,855 |
| Liabilities. Value of operating payables at end of year | 2017-12-31 | $41,484 |
| Liabilities. Value of operating payables at beginning of year | 2017-12-31 | $43,556 |
| Total non interest bearing cash at end of year | 2017-12-31 | $190,595 |
| Total non interest bearing cash at beginning of year | 2017-12-31 | $164,340 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Value of net income/loss | 2017-12-31 | $-52,688 |
| Value of net assets at end of year (total assets less liabilities) | 2017-12-31 | $194,460 |
| Value of net assets at beginning of year (total assets less liabilities) | 2017-12-31 | $247,148 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2017-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2017-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2017-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2017-12-31 | $220,316 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2017-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2017-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2017-12-31 | No |
| Contributions received in cash from employer | 2017-12-31 | $373,125 |
| Employer contributions (assets) at end of year | 2017-12-31 | $40,703 |
| Employer contributions (assets) at beginning of year | 2017-12-31 | $48,035 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2017-12-31 | $77,758 |
| Contract administrator fees | 2017-12-31 | $58,821 |
| Liabilities. Value of benefit claims payable at end of year | 2017-12-31 | $5,940 |
| Liabilities. Value of benefit claims payable at beginning of year | 2017-12-31 | $13,186 |
| Did the plan have assets held for investment | 2017-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2017-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2017-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2017-12-31 | Unqualified |
| Accountancy firm name | 2017-12-31 | CLIFTONLARSONALLEN, LLP |
| Accountancy firm EIN | 2017-12-31 | 410746749 |
| 2016 : AMERICA'S PRIDE, INC. HEALTH & WELFARE TRUST 2016 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2016-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-12-31 | $56,742 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-12-31 | $103,113 |
| Total income from all sources (including contributions) | 2016-12-31 | $411,081 |
| Total loss/gain on sale of assets | 2016-12-31 | $0 |
| Total of all expenses incurred | 2016-12-31 | $364,301 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2016-12-31 | $367,345 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2016-12-31 | $411,081 |
| Value of total assets at end of year | 2016-12-31 | $303,890 |
| Value of total assets at beginning of year | 2016-12-31 | $303,481 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2016-12-31 | $-3,044 |
| Total interest from all sources | 2016-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2016-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2016-12-31 | No |
| Was this plan covered by a fidelity bond | 2016-12-31 | Yes |
| Value of fidelity bond cover | 2016-12-31 | $70,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2016-12-31 | Yes |
| Amount of non-exempt transactions with any party-in-interest | 2016-12-31 | $91,515 |
| Assets. Other investments not covered elsewhere at end of year | 2016-12-31 | $0 |
| Assets. Other investments not covered elsewhere at beginning of year | 2016-12-31 | $16,348 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2016-12-31 | $91,515 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2016-12-31 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2016-12-31 | $13,186 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2016-12-31 | $3,931 |
| Administrative expenses (other) incurred | 2016-12-31 | $-71,174 |
| Liabilities. Value of operating payables at end of year | 2016-12-31 | $26,268 |
| Liabilities. Value of operating payables at beginning of year | 2016-12-31 | $55,815 |
| Total non interest bearing cash at end of year | 2016-12-31 | $164,340 |
| Total non interest bearing cash at beginning of year | 2016-12-31 | $239,313 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-12-31 | No |
| Value of net income/loss | 2016-12-31 | $46,780 |
| Value of net assets at end of year (total assets less liabilities) | 2016-12-31 | $247,148 |
| Value of net assets at beginning of year (total assets less liabilities) | 2016-12-31 | $200,368 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2016-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2016-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2016-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2016-12-31 | $286,626 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2016-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2016-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2016-12-31 | No |
| Contributions received in cash from employer | 2016-12-31 | $411,081 |
| Employer contributions (assets) at end of year | 2016-12-31 | $48,035 |
| Employer contributions (assets) at beginning of year | 2016-12-31 | $47,820 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2016-12-31 | $80,719 |
| Contract administrator fees | 2016-12-31 | $68,130 |
| Liabilities. Value of benefit claims payable at end of year | 2016-12-31 | $17,288 |
| Liabilities. Value of benefit claims payable at beginning of year | 2016-12-31 | $43,367 |
| Did the plan have assets held for investment | 2016-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2016-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2016-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2016-12-31 | Unqualified |
| Accountancy firm name | 2016-12-31 | CLIFTONLARSONALLEN, LLP |
| Accountancy firm EIN | 2016-12-31 | 410746749 |
| 2011 : AMERICA'S PRIDE, INC. HEALTH & WELFARE TRUST 2011 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2011-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-12-31 | $667,606 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-12-31 | $570,160 |
| Total income from all sources (including contributions) | 2011-12-31 | $275,432 |
| Total loss/gain on sale of assets | 2011-12-31 | $0 |
| Total of all expenses incurred | 2011-12-31 | $264,087 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2011-12-31 | $216,297 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2011-12-31 | $271,133 |
| Value of total assets at end of year | 2011-12-31 | $810,192 |
| Value of total assets at beginning of year | 2011-12-31 | $701,401 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2011-12-31 | $47,790 |
| Total interest from all sources | 2011-12-31 | $4,299 |
| Total dividends received (eg from common stock, registered investment company shares) | 2011-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2011-12-31 | No |
| Administrative expenses professional fees incurred | 2011-12-31 | $267 |
| Was this plan covered by a fidelity bond | 2011-12-31 | Yes |
| Value of fidelity bond cover | 2011-12-31 | $70,000 |
| If this is an individual account plan, was there a blackout period | 2011-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2011-12-31 | No |
| Administrative expenses (other) incurred | 2011-12-31 | $25,264 |
| Liabilities. Value of operating payables at end of year | 2011-12-31 | $5,772 |
| Liabilities. Value of operating payables at beginning of year | 2011-12-31 | $10,283 |
| Total non interest bearing cash at end of year | 2011-12-31 | $32,349 |
| Total non interest bearing cash at beginning of year | 2011-12-31 | $34,243 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-12-31 | No |
| Value of net income/loss | 2011-12-31 | $11,345 |
| Value of net assets at end of year (total assets less liabilities) | 2011-12-31 | $142,586 |
| Value of net assets at beginning of year (total assets less liabilities) | 2011-12-31 | $131,241 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2011-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2011-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2011-12-31 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2011-12-31 | $746,726 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2011-12-31 | $622,709 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2011-12-31 | $622,709 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2011-12-31 | $4,299 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2011-12-31 | $30,957 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2011-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2011-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2011-12-31 | No |
| Contributions received in cash from employer | 2011-12-31 | $271,133 |
| Employer contributions (assets) at end of year | 2011-12-31 | $31,117 |
| Employer contributions (assets) at beginning of year | 2011-12-31 | $44,449 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2011-12-31 | $185,340 |
| Contract administrator fees | 2011-12-31 | $22,259 |
| Liabilities. Value of benefit claims payable at end of year | 2011-12-31 | $661,834 |
| Liabilities. Value of benefit claims payable at beginning of year | 2011-12-31 | $559,877 |
| Did the plan have assets held for investment | 2011-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2011-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2011-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2011-12-31 | Unqualified |
| Accountancy firm name | 2011-12-31 | INEICH & COPMANY. LLP |
| Accountancy firm EIN | 2011-12-31 | 562552172 |
| EYE MED VISION CARE (National Association of Insurance Commissioners NAIC id number: 98512 ) |
| Policy contract number | CLLMBAPI5 |
| Policy instance | 5 |
| Insurance contract or identification number | CLLMBAPI5 | | Number of Individuals Covered | 80 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $43 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,739 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $43 | | Insurance broker organization code? | 5 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 645505 |
| Policy instance | 3 |
| Insurance contract or identification number | GL 645505 | | Number of Individuals Covered | 79 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $170 | | Total amount of fees paid to insurance company | USD $373 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,697 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $170 | | Amount paid for insurance broker fees | 373 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER POLICY RELATED SERVICE FEES | | Insurance broker organization code? | 3 |
|
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | FCE0-001 |
| Policy instance | 4 |
| Insurance contract or identification number | FCE0-001 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $250 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | CLLMBAPI3 |
| Policy instance | 2 |
| Insurance contract or identification number | CLLMBAPI3 | | Number of Individuals Covered | 79 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $666 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,303 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $666 | | Insurance broker organization code? | 5 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 704578 |
| Policy instance | 1 |
| Insurance contract or identification number | 704578 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $24,403 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 645704 |
| Policy instance | 5 |
| Insurance contract or identification number | VAR 645704 | | Number of Individuals Covered | 132 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $160 | | Total amount of fees paid to insurance company | USD $211 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,598 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $160 | | Amount paid for insurance broker fees | 211 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER POLICY RELATED SERVICE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS, INC. |
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| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | FCE0-001 |
| Policy instance | 4 |
| Insurance contract or identification number | FCE0-001 | | Number of Individuals Covered | 82 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,164 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 645505 |
| Policy instance | 3 |
| Insurance contract or identification number | GL 645505 | | Number of Individuals Covered | 132 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $931 | | Total amount of fees paid to insurance company | USD $1,215 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $9,305 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $931 | | Amount paid for insurance broker fees | 1215 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER POLICY RELATED SERVICE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS, INC. |
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| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | CLLMBAPI3 |
| Policy instance | 2 |
| Insurance contract or identification number | CLLMBAPI3 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $64,886 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 5 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS, INC. |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 704578 |
| Policy instance | 1 |
| Insurance contract or identification number | 704578 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2016-04-01 | | Insurance policy end date | 2017-03-31 | | Total amount of commissions paid to insurance broker | USD $6,668 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $145,246 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,668 | | Insurance broker organization code? | 3 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS, INC. |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR645704 |
| Policy instance | 3 |
| Insurance contract or identification number | VAR645704 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $20 | | Total amount of fees paid to insurance company | USD $433 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,924 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL645505 |
| Policy instance | 2 |
| Insurance contract or identification number | GL645505 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $112 | | Total amount of fees paid to insurance company | USD $2,220 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $10,326 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | GER-P08-249R |
| Policy instance | 1 |
| Insurance contract or identification number | GER-P08-249R | | Number of Individuals Covered | 48 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EXCESS LOSS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $15,678 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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